Referral Guidance

GP referrals to MAU / Ambulatory Care Centre

Monday to Friday 10:00 – 18:00

All referrals and requests for advice to Consultant Acute Physician for phone triage (via Bed Bureau). At times the Consultant is not available calls will be taken by the MAU Registrar.

Out of Hours

Via Bed Bureau (01332 789099). BB is available 24:7. In difficult or uncertain cases the Medical Registrar covering MAU may be asked for advice.

Inclusion criteria for MAU

Adults over the age of 16 with urgent or emergency medical problems. Patients aged 16 or 17 should usually be given the choice of paediatric or adult services.

Referral letters should ideally accompany the patient or, if this is not possible, be emailed to Bed Bureau via their secure nhs email address: dhft.bedbureaurdh@nhs.net.

Inclusion criteria for ACC

Adults over the age of 16 with urgent or emergency medical problems. These patients should be independently mobile, self-caring and suitable to be looked after in a clinic environment. Patients who are confused, agitated or have grossly abnormal vital signs are unsuitable. Some patients may be suitable to attend electively the next day.

ACC is open 8:30 - 23:00 (final referral usually at 20:00) Monday to Friday and 12:00 - 20:00 (final referral 18:00) on weekends and bank holidays.

These patients should be transferred by 999 ambulance direct to the Emergency Department.

Speciality advice

Most specialities are part of Clinician Connect which aims to reply to semi-urgent queries within 48 hours by phone or email. Clinician Connect is accessible through Bed Bureau. Some specialities will also have a Consultant or Registrar on call for urgent advice.

Guidance regarding specific conditions:

Abdominal pain – all severe abdominal pain should be referred to Surgery.

Alcohol withdrawal – mild withdrawal symptoms should be managed with advice to reduce intake gradually and referral to community alcohol services. Patients with severe symptoms at risk of life-threatening complications will need admission (this should be via ED if they are violent or aggressive with acute confusion). Patients wishing for an elective detox should be referred to community services.

Anaemia - Acute severe symptomatic anaemia will usually be accepted to MAU with the exception of lower GI bleed (Surgery), epistaxis (ENT) and menorrhagia (Gynaecology).

Transfusion - NICE guidance recommends restrictive transfusion thresholds for those who do not have major haemorrhage, acute coronary syndrome, or require recurrent transfusions. This threshold is 70 g/L, with a post transfusion target of 70 - 90. [https://www.nice.org.uk/guidance/ng24].

Intravenous iron pathway - new onset symptomatic iron deficiency Hb < 80 g/L may be considered for intravenous iron via ACC if no active bleeding and unsuitable for oral supplementation.

Ascites – known liver patients with diuretic-resistant ascites requiring recurrent paracentesis (and no other acute issue) can be referred to Liver Specialist Nurses during working hours to arrange drainage on EPU.

Back pain – severe back pain should not be directly admitted to MAU.

Cardiac Chest Pain – prolonged suspected cardiac chest pain (> 15 minutes) or symptoms suggestive of unstable or crescendo angina will need assessment by Medicine. Stable symptoms can usually be referred to Rapid Access Chest Pain Clinic. If the patient is having ongoing suspected cardiac chest pain that has not settled at time of referral they should go directly to ED via 999 ambulance.

Cancer – suspected malignancy can usually be managed by 2WW referral to the appropriate speciality. The patient should only be referred to Acute Medicine if they are also acutely unwell requiring hospital treatment.

Cord Compression – suspected cord compression should go to ED. There is a metastatic spinal cord compression facilitator who may be involved to arrange management thereafter.

Chemotherapy patients – should have emergency phone number for complications (24:7). CDU (shared between Oncology and Haematology) is open Mon – Thu 9:00 - 19:00 (last admission 18:00), Fri 9:00 – 1800 (last admission 17:00). Weekends 9:00 – 16:00 Oncology patients may be seen on 303 by the SpR. Admission outside these times would be via MAU.

Dermatology – if the patient has suspected erythroderma or is systemically unwell should be seen in ACC / MAU. Stable patients should be discussed with the Dermatology Registrar based at LRCH during weekday working hours (before 16:00 Friday).

Diabetes

New T1DM – if not suspected DKA the point of contact is the Diabetic Specialist Nurse via Clinician Connect who will arrange same day review.

Diabetic foot infections – referrals are generally seen in foot clinic within 48 hours. If referrals are received Mon, Tues or Thurs patients are usually seen in the Wed or Fri clinic. If the call is coming in on a Wed or Fri and GP feels the patient urgent review they should contact Medical Speciality OPD regarding same day review in clinic.

Hyperglycaemia – in an otherwise well patient can be discussed directly with Endocrine.

DVT- usually direct to DVT clinic. Please note this is a nurse-led service for a lower limb DVT rule in / out and does not offer any other diagnostic or referral service beyond this. Immobile / bedbound patients will usually need to be discussed with a clinician for elective admission via MAU Triage for Doppler (with bridging anticoagulation in the community).

Geriatrics – intermediate care, urgent social support, and therapies are available in the community via single point of access. For complex cases that cannot be resolved via SPA and do not clearly need medical admission the Geriatric Consultant can be contacted 9:00 – 17:00 via switchboard.

Haematuria – should be referred to Urology unless clearly secondary to coagulopathy or thrombocytopenia.

HIV – GU Medicine is based at LRCH. CD4 counts and viral load are kept in a database accessible via GUM.

Neurosurgery – all patients with significantly reduced GCS should be admitted via ED. Stable / no significantly reduced GCS patients with suspected spontaneous intracranial haemorrhage or space occupying lesion can be assessed by Acute Medicine. Trauma should not be directly admitted to Medicine. Our local Neurosurgical unit is QMC Nottingham.

Oncology – Oncology SpRs will take calls via switchboard up to 7pm on weekdays. Weekends there is a SpR or Associate Specialist to 5pm. Patients on systemic cancer treatment (chemo, tyrosine kinase inhibitors, immunotherapy) attending between 9:00 -18:00 Mon – Fri or 9:00 – 16:00 weekends will usually be able to be assessed by the Oncology team on CDU or 303 by arrangement.

Palliative Care – The Nightingale Macmillan Unit (NMU) runs a dynamic waiting list and admissions are prioritised based on patients’ clinical need. Patients are usually admitted for difficult symptom control and/or complex psychological problems. Due to the number of admission requests for symptom control, patients comfortably dying with no specialist palliative care needs may not be a clinical priority. It may be appropriate for patients with acute, potentially reversible problems to be admitted to MAU for treatment despite their progressive underlying disease. To request admission to NMU, Mon to Fri 9am to 5pm phone 86060; out of hours call the Palliative Medicine Consultant on-call.

Other Specialist Palliative Care services:

Community Palliative Care Team will assess urgent referrals within 2 days, the consultant and StR can also assess people at home.

Palliative Medicine Outpatient clinics at RDH and in the community, urgent referrals will be seen within 1 week; referrals can be emailed to dhft.pallmedsecs@nhs.net

24 hour Nurse-held telephone advice line primarily for patients and carers known to the service in the community.

24/7 access to a Palliative Medicine Consultant

Mon to Fri, 9am -5pm via Palliative Medicine Secretaries (ext 88794)

Out of Hours via switchboard asking for the Palliative Medicine Consultant on-call

Papilloedema – possible papilloedema patients identified by community optometrists have their retinal images transferred to ophthalmology for review and exclusion of pseudo-papilloedema. If presenting to GP patients should be referred directly to ophthalmology for early outpatient review unless they have red flag signs suggestive of raised intracranial pressure in which case they should be seen in MAU / ACC.

PEGs – blocked / dislocated PEGs can usually be discussed with the Nutrition Specialist Nurses during normal working hours.

Pulmonary embolism – Suspected PE at low risk of life threatening complications (calculated with PESI score) may be managed via ACC. High risk patients will usually need to be investigated as an inpatient.

Postpartum – complications in the immediate postpartum period should go to Obstetrics. MAU does not have facilities for nursing mothers.

Pregnancy – patients over 20 weeks gestation should be referred to Obstetrics.

Rheumatology – advice is usually available directly from the On Call Rheumatology Consultant Mon-Fri 9:00-17:00 via switchboard.

Social issues – should not be referred to medicine other than in exceptional circumstances. Help for vulnerable people with poor housing conditions can be accessed through the council via http://www.derby.gov.uk/healthyhousing

Stroke / TIA – Potential candidates for thrombolysis (can be performed up to 4.5 hours from time of onset) should be blue-lighted to ED. Other suspected strokes and high risk TIAs should be referred direct to Stroke team. Low risk TIAs to TIA Clinic. Stroke patients should not be referred to MAU.

Urosepsis / Pyelonephritis – Exclusions for admission to MAU are known or suspected renal calculi, nephrostomies, known abnormalities of the renal tract, frank haematuria, blocked suprapubic catheter, UTI in males < 50, or pyelonephritis in males. These groups should be admitted to Urology.